Department of Internal Medicine, University of California Davis School of Medicine, 4150 V St, Sacramento, CA, 95817, USA.
Department of Internal Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA.
J Gen Intern Med. 2022 Aug;37(11):2803-2810. doi: 10.1007/s11606-022-07528-y. Epub 2022 May 31.
Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. As such, thoughtful clinical guidance is required to avoid having young women who are troubled by their menses, dose reduce, or prematurely discontinue their anticoagulation, leaving them at increased risk of recurrent thrombosis. Informed by a review of the medical literature, we present current recommendations for assisting patients requiring anticoagulation with menstrual management, prevention of hemorrhagic ovarian cysts, and avoiding unintended pregnancy. The subdermal implant may be considered a first-line option for those requiring anticoagulation, given its superior contraceptive effectiveness and ability to reliably reduce risk of hemorrhagic ovarian cysts. All progestin-only formulations-such as the subdermal implant, intrauterine device, injection, or pills-are generally preferred over combined hormonal pills, patch, or ring. Tranexamic acid, and in rare cases endometrial ablation, may also be useful in managing menorrhagia and dysmenorrhea. During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.
抗凝治疗给育龄期女性带来了独特的挑战。开具抗凝药物的临床医生必须就一系列问题对患者进行咨询，包括月经和发生出血性卵巢囊肿的可能性，以及致畸风险和母乳喂养安全性。多达 70%接受抗凝治疗的年轻女性会出现异常子宫出血。因此，需要进行深思熟虑的临床指导，以避免因月经问题而使年轻女性减少剂量或提前停止抗凝治疗，从而使她们面临更高的血栓复发风险。我们在回顾医学文献的基础上，提出了目前关于抗凝治疗期间月经管理、预防出血性卵巢囊肿以及避免意外怀孕的建议。对于需要抗凝治疗的患者，皮下埋植剂可被视为首选方案，因其具有卓越的避孕效果和可靠降低出血性卵巢囊肿风险的能力。所有孕激素避孕药，如皮下埋植剂、宫内节育器、注射剂或药丸，通常优于联合激素避孕药、贴剂或环。氨甲环酸，在极少数情况下，子宫内膜消融术，也可用于治疗月经过多和痛经。怀孕期间，仍推荐使用依诺肝素作为抗凝药物，华法林禁用。母乳喂养的女性可以使用华法林，但不建议使用直接口服抗凝剂，因为其安全性数据有限。本临床医生实用指南旨在为育龄期女性讨论抗凝治疗的风险和获益提供信息。
